Idiopathic Perforation of the Gallbladder

Abstract

AB Abbad, A Baez-Giangreco, M Afzal, Idiopathic Perforation of the Gallbladder. 2000; 20(5-6): 417-418 Gallbladder perforation is an infrequent but potentially fatal disease. It is usually a complication of acute cholecystitis with or without gallstones and has rarely been reported in association with trauma, neoplasia, chemotherapy, vascular disease or pregnancy. [1][2][3][4][5][6] However, idiopathic perforation of the gallbladder without any demonstrable cause is an extremely rare occurrence, 7 and is the subject of this report. Case ReportA previously healthy 30-year-old Nepalese man presented to the emergency department of Dar Al-Shefa Hospital, Riyadh, as a result of two days' history of severe pain in the epigastrium, right hypochondrium and right lumbar region. The patient vomited once and had no urinary trouble. There was no history of trauma or drug abuse. His vital signs were as follows: pulse 99/min; blood pressure 140/100 mm Hg; respiration 24/min; and temperature 37.8°C. Physical examination revealed tenderness with rebound pain in the epigastrium, right upper quadrant and right lumbar region. Bowel sounds were faint, and no significant distention of the abdomen was noted. Laboratory studies revealed white blood cell count to be 18,500/mm 3 with predominance of neutrophils; hemoglobin 16 g/dL; hematocrit 43.8% and platelets 311,000/mm 3 ; SGPT 75 U/L (normal up to 42); SGOT 84 U/L (normal up to 37); alkaline phosphatase 166 U/L (normal up to 306); serum amylase 41 U/L (normal up to 90); BUN 11 mg/dL (normal 9-20); Na + 138 mmol/L (normal 135-155); and K + 3.5 mmol/L (normal 3.5-5.5). The Widal test, Sickling test and blood cultures were all negative. Urine analysis revealed no significant abnormality. The flat and upright abdominal radiographs were interpreted as suggestive of an adynamic ileus pattern and revealed no gas under the diaphragm. Ultrasonographic examination revealed a slight thickening of the gallbladder wall but no stones or distention. A small amount of free fluid was observed in the pelvis. With a provisional diagnosis of peritonitis secondary to perforated duodenal ulcer, acute cholecystitis or sub-hepatic retrocecal appendicitis, an emergency laparotomy was performed using a midline vertical incision about 12 hours after the admission and after initial hydration. The abdominal viscera were stained yellowish green. Bile was seen leaking through a small hole in the body of the gallbladder near the fundus. The gallbladder wall was slightly thickened, and it was neither distended nor inflamed. Other abdominal viscera were unremarkable. A small amount of bile-stained fluid was noted in the right paracolic gutter and pelvis. Bile culture was obtained and cholecystectomy was performed.